Published online: 2019-09-26

Original Article

Diagnostic role of capsule in patients of obscure gastrointestinal bleeding after negative CT enterography

Jaswinder Singh Sodhi, Ajaz Ahmed, Abid Shoukat, Bashir Ahmed Khan, Gul Javid, Mushtaq Ahmed Khan, Manjeet Singh, Feroz Shaheen, Shaheen Nazir, Zaffar Iqbal Kawoosa

Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

Abstract Background and Objectives: Computed tomographic enterography (CT-EG) has emerged a useful tool for the evaluation of small bowel in patients of obscure gastrointestinal bleeding (OGIB). However, CT-EG may be negative in about 50-60% of patients. We aimed to see the efficacy of capsule endoscopy (CE) in patients of OGIB, who had initial negative CT-EG. Materials and Methods: All consecutive patients of OGIB after initial hemodynamic stabilization were subjected to CT-EG. Those having negative CT-EG were further evaluated with CE. Results: Fifty-five patients of OGIB with mean standard deviation age, 52.7 (19.0), range 18-75 years, women 31/55 (56.4%) were subjected to CT-EG. Nine (17.6%) patients had positive findings on CT-EG, which included mass lesions in six, thickened wall of distal ileal loops, narrowing, and wall enhancement in two and jejunal wall thickening with wall hyperenhancement in one patient. Forty-two patients had negative CT-EG of which 25 underwent CE for further evaluation. CE detected positive findings in 11 of 25 (48%) patients which included vascular malformations in three, ulcers in seven, and fresh blood without

identifiable source in one. The diagnostic yield of CE in overt OGIB was more compared to occult OGIB ((7/14, 50%) vs (4/11, 36.4%) P = 0.2) and was higher if performed within 2 weeks of active gastrointestinal (GI) bleed (P = 0.08). Conclusions: In conclusion, CE is an additional tool in the evaluation of obscure GI bleed, especially mucosal lesions which can be missed by CT-EG. Key words Capsule endoscopy, , computed tomographic enterography, obscure gastrointestinal bleed, upper gastrointestinal endoscopy

Introduction GI endoscopy and colonoscopy. Overt OGIB is defined as visible GI bleeding (malena or hematochezia) and can be Obscure gastrointestinal bleeding (OGIB) is defined as occult categorized further as active (evidence of ongoing bleeding) or overt bleeding of unknown origin that persists or recurs and inactive bleeding. OGIB is designated as occult when after an initial negative endoscopic evaluation including upper there is no evidence of gross bleeding, that is, unexplained iron deficiency anemia (IDA) suspected to be caused by GI Access this article online blood loss. Quick Response Code Website: About 5% of GI bleeding occurs between the ligament of Treitz www.jdeonline.in and the ileocecal valve.[1] Vascular malformations of the small bowel account for 30-40% of OGIB in elderly population.[2] DOI: Nonsteroidal anti-inflammatory drug (NSAID) enteropathy 10.4103/0976-5042.132403 and inflammatory bowel disease have been associated with erosions, ulcers, and strictures of the small bowel and may

Address for correspondence: Dr. Jaswinder Singh Sodhi, Department of Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar - 190 011, Kashmir, India. E-mail: [email protected]

Journal of Digestive Endoscopy Vol 4 | Issue 4 | October-December 2013 107 Sodhi, et al.: Capsule endoscopy in obscure gastrointestinal bleed present as OGIB.[3,4] Small bowel tumors (gastrointestinal for urgently performed CE (within 48 h after admission) in stromal tumors (GISTs), lymphomas, adenocarcinomas, and patients with mild to moderate acute overt OGIB suggest carcinoids) are most common cause of OGIB in patients that early intervention with CE may enhance diagnostic of younger age group.[5] The other causes include Meckel’s effectiveness. diverticulitis,[6] radiation enteropathy,[7] Dieulafoy’s lesion,[8] hemosuccus pancreaticus,[9] and small bowel varices.[10] Despite the utility of CT-EG in establishing the cause of OGIB, negative rate of CT-EG in patients of OGIB is quite high. The Before evaluating small bowel, upper and lower GI aim of this study was to determine the diagnostic efficacy of are repeated in patients with OGIB because of initial CE in patients of OGIB who had initial negative CT-EG. endoscopic miss rates in some patients.[11] Diagnostic methods for the evaluation of small bowel includes procedures like Materials and Methods small-bowel follow-through and enteroclysis, angiography, scintigraphy, push , and intraoperative enteroscopy. Subject population However, all these techniques are either time consuming, This study was conducted in the Department of operator dependent, require sedation, are relatively insensitive, Gastroenterology at Sher-i-Kashmir Institute of Medical or are highly invasive.[12] Newer technologies such as Sciences (SKIMS) along with Department of Radiodiagnosis capsule endoscopy (CE), double balloon enteroscopy or CT from December 2010 to July 2012. Written informed consent enterography (CT-EG) have better access to small bowel and was obtained from all patients who participated in this can provide improved care for patients with OGIB.[13] study. The study was approved by the institutional ethics and radiation safety committees. All patients of OGIB both CT-EG is a noninvasive imaging technique that uses neutral overt and occult were included in this study after they were intraluminal and intravenous contrast to evaluate the small resuscitated, stabilized, and were not actively bleeding. These bowel and has been particularly useful in enhancement of patients initially had CT-EG and those who had negative the small bowel wall in inflammatory bowel disease. 64-slice CT-EG were subjected to CE. The non-GI causes of IDA in CT systems has improved spatial and temporal resolution patients with occult OGIB with negative compared to 8- and 16-slice system and permits scanning test (FOBT) were excluded with history, examination, and of larger volumes of body in lesser amount of time without relevant investigations. Hematological indices and iron profile compromising on slice thickness. The role of CT-EG in the

were used for diagnosis of IDA. Exclusion criteria included evaluation of OGIB is evolving.[14-17] The use of neutral enteric age <18 years, pregnancy, actively bleeding patient, unable contrast agents such as water, polyethylene glycol (PEG), to give consent, known allergy to iodized contrast material, combined with the use of intravenous contrast optimizes renal insufficiency with creatinine >2, unable to swallow the luminal distention and depicts attenuation differences capsule, and small bowel obstruction. among the wall layers, the fluid-filled lumen and the adjacent mesenteric fat.[18,19] Initial experience with CT-EG reported Study protocol successful identification of a bleeding source in 45% of patients CT-EG was performed after overnight fast. A total of 2,000 ml with OGIB, including three lesions that were missed on CE.[14] of PEG electrolyte solution was given within 60 min prior to In a study of 26 patients with massive GI bleeding, a multiple scanning, with first 1,500 ml ingested over first 15 min and two detector CT had an accuracy of 89% and positive predictive 250 ml aliquots consumed 25 and 15 min prior to scanning, value of 95%.[20] The location of lesions corresponded exactly respectively. A 100 ml of iohexol (300 mg/ml) (Omnipaque, to that of active bleeding on angiograms in all patients. Despite Amershal GE healthcare, Princeton, NJ) was power-injected above advantages negative CT-EG in patients of OGIB is intravenously at a rate of 4 ml/s through antecubital catheter quite high. using dual head injector (Optivantage DH, Mallinckrodt) followed by saline flush. Scanning was performed on CE has been more efficient in picking up mucosal lesions 64-channel multidetector row CT scanners (Siemens Sensation compared to CT-EG. It is safe, noninvasive, well-accepted, and 64, Siemens Medical Solution, Forcheim, Germany) from tolerated by the patient. This technique gives high resolution diaphragm to the symphysis pubis. Images were acquired with a images of the whole small bowel, avoiding any sedation or section thickness of 2.0-2.5 mm. Image evaluation was done by radiation exposure. The capsules currently in use measure a consultant radiologist having more than 12 years’ experience 26 × 11 mm, is propelled by peristalsis and has an imaging in interpreting CT studies of the GI tract. capacity of two frames per second over 8 h. A meta-analysis of 14 prospective studies showed a higher yield (56%) for clinically CE was performed after overnight 8 h fast. Patients were significant lesions with CE than with push enteroscopy (26%) on liquid diet for 24 h before the procedure and were given or small bowel follow through (6%). In comparison with CT 1,000 ml of PEG solution on the night prior to procedure. angiography (CTA) and standard angiography, CE detected Each patient ingested the capsule in sitting position (Mirocam more bleeding source lesions (72% with CE vs 24% with CTA Capsule Endoscopy, IntroMedic Co., Seoul, Korea). Patients and 56% with angiography).[21] High diagnostic yields (91.9%) were allowed to take clear liquids after 2 h and liquid diet after Journal of Digestive Endoscopy 108 Vol 4 | Issue 4 | October-December 2013 Sodhi, et al.: Capsule endoscopy in obscure gastrointestinal bleed

4 h of procedure. When image acquisition was completed, Results of CE the data from the recording device was downloaded to a Among 25 patients who ingested capsule, one patient had computer workstation, where the images were processed and image recording of only 2 h due to battery failure in capsule. viewed by two consultant gastroenterologists independently In remaining 24, CE detected positive findings (P2 lesions) and they were not aware of patient’s initial CT-EG report. in 11 of 25 (44%) and P1 lesions in four patients. P2 lesions CE findings were classified as highly relevant (P2) or less included vascular malformation in three [Figure 3], jejunal relevant (P1 or P0) lesions according to the standard practice ulcers in one, ileal ulcers in five, blood in terminal guidelines.[22] More than one P2 lesion was reported as in one, and ileal ulcers with stricture in one [Table 3]. The positive, whereas, only a P1 lesion or no abnormality (P0) was diagnostic yield of CE in patients with overt OGIB was more reported as negative. The quality of the capsule endoscopic compared to patients of occult OGIB ((7/14, 50%) vs (4/11, examination was evaluated by using a three-point scale of 36.4%) P = 0.2). Fourteen patients (56%) underwent CE within excellent, fair, or nondiagnostic, depending on the amount of feces or fluid that hindered visualization of the small-bowel Table 1: Outcome of CT-EG in patients of OGIB (n=51) [23] mucosal surface. Diagnosis Overt 27 Occult 24 Total 51 GIST 3 1 4 Statistical analysis Duodenal adenocarcinoma 0 1 1 All statistical analysis was performed with Statistical Package Duodenal carcinoid 1 0 1 for Social Sciences (SPSS) version 13.0 (SPSS Inc, Chicago, IL, Jejunal stricture 0 1 1 USA). Data are presented as mean (standard deviation (SD)). Ileal wall thinking with narrowing 0 2 2 Continuous and categorical values variables were analyzed by Total (%) 4/27 (14.8) 5/24 (20.8) 9/51 (17.6) Fisher’s exact test and Mann-Whitney U-test. A P value less GIST=Gastrointestinal stromal tumor, CT-EG=Computed tomographic enterography, OGIB=Obscure gastrointestinal bleed than 0.05 was considered significant.

Table 2: Baseline characteristics of patients of OGIB with Results negative CT-EG (n=25) Age, mean (SD) 52.7 (19.0) Fifty-five patients of OGIB, mean (SD) age 52.7 (19.0), Range 18-75 range (18-75 years), women 31/55 (56.4%) were subjected to Sex CT-EG. Four patients had inadequate luminal distension to Women, N (%) 14/25 (56.4) interpret CT-EG and were excluded. Nine (17.6%) patients Overt OGIB, N (%) 14 (56) had positive findings on CT-EG, which included six mass No of bleeding episodes, mean (range) 3 (1-10) lesions in small bowel [Figure 1], two patients had thickened Occult OGIB, N (%) 11 (44) wall of distal ileal loops, narrowing, and wall enhancement IDA with FOBT positive, N (%) 7 (63.6) IDA with FOBT negative, N (%) 4 (36.4) and one patient had jejunal wall thickening with narrowing Duration of illness (weeks), mean (SD) 8.9 (9.1) and wall hyperenhancement [Figure 2]. Patients with mass Range (1-36) lesions were subjected to exploratory laprotomy and had mass Hemoglobin (g/dl), mean (SD), 6.8 (1.6) lesions consistent with CT-EG findings. Histopathology of Serum iron (μg/dl), mean (SD) 47 (7.5) these lesions revealed GIST in four, duodenal adenocarcinoma No of upper GI endoscopies, mean (range) 2 (1-5) in one, and duodenal carcinoid in one [Table 1]. Forty-two No of , mean (range) 1.24 (1-2) patients had negative CT-EG, of which 25 (59.5%) underwent OGIB=Obscure gastrointestinal bleed, CT-EG=Computed tomographic enterography, IDA=Iron defi ciency anemia, SD=Standard deviation, CE for further evaluation. The baseline characteristics of FOBT=Fecal occult blood test patients who received CE are shown in Table 2.

a b a Figure 1: Computed tomography (CT) enterography in a patient of b obscure gastrointestinal bleeding (OGIB) showing enhancing mass Figure 2: (a) CT-enterography showing jejunal stricture. (b) Surgical lesion in ileum with a feeding vessel specimen showing stricture (adenocarcinoma) Journal of Digestive Endoscopy Vol 4 | Issue 4 | October-December 2013 109 Sodhi, et al.: Capsule endoscopy in obscure gastrointestinal bleed

2 weeks of last bleeding episode and 11 (44%) patients after exploratory , which revealed multiple ileal 2 weeks. Seven of 14 patients had positive CE within 2 weeks, ulcers with strictures. Capsule was removed followed by and four of 11 patients had positive CE after 2 weeks of last resection anastomosis of diseased segment. Histopathology bleeding episode (P = 0.08) [Table 4]. of removed segment revealed Crohn’s disease. Two patients with nonspecific ulcers with oozing of blood [Figure 5] had The small bowel ulcers were the most common finding which history of nonsteroidal anti-inflammatory drug (NSAID) and occurred in seven of 11 patients [Figures 4a,5 and 6]. Two aspirin intake. These two patients were kept under observation patients of ileal ulcers underwent double balloon enteroscopy only and responded to iron therapy without further bleeding. and findings were similar with CE. These two patients Among three patients of vascular malformation, one had nonspecific ulcers on biopsy and received coagulation patient was put on thalidomide for 2 months without any therapy. One patient with ileal ulcer had associated stricture improvement in hemoglobin and thereafter, the drug was with retention of capsule [Figure 4]. This patient underwent stopped. The other two patients were kept under observation, one patient did not develop further bleeding over a period Table 3: Patients of OGIB with positive capsule endoscopic of 10-12 months and other one patient developed recurrent fi ndings (N=11) GI bleed on follow-up and was transfusion dependent. One Clinical features Capsule endoscopy fi nding patient had blood in small bowel without any identifiable Overt OGIB (malena) Multiple ulcers seen from jejunum to cause [Figure 7]. This patient was offered surgical intervention terminal ileum which he refused [Table 3]. Abdominal pain, diarrhea, Multiple ulcers in jejunum and ileum symptomatic IDA Follow-up of CE negative patients Hypertension, coronary Multiple superfi cial ulcers in distal artery disease on aspirin. ileum Thirteen patients (52%) had normal CT-EG and CE, out of Symptomatic IDA which six patients had overt OGIB and seven patients had Overt OGIB (malena) Diffuse fl at ulcers in ileum with fresh occult OGIB. Among six patients of overt OGIB, two patients blood at places underwent double balloon enteroscopy because of recurrent Overt OGIB (malena) Multiple fl at submucosal hemorrhages along blood vessels seen in ileum Overt OGIB (hematochezia) Multiple scattered large and small Table 4: Diagnostic yield of capsule endoscopy in relation abdominal pain ulcers in ileum associated with with time of bleed stricture and divericulae Capsule endoscopy Timing of bleed Total

Symptomatic anemia (IDA) Few fl at submucosal hemorrhages results (N) Within 2 weeks More than 2 weeks seen in D1, D2 and multiple Positive 7 4 11 submucosal hemorrhages in jejunum Negative 6 7 13 Overt OGIB (malena) Multiple ileal ulcers, with oozing of blood from one of the ulcer Total 14 11 24 Overt OGIB (malena) Fresh and old blood with clots seen P=0.08 in ileum Overt OGIB (malena) Two superfi cial ulcers in proximal ileum, one of ulcer oozing blood Symptomatic anemia (IDA) Multiple punctate hemorrhagic spots seen in ileum OGIB=Obscure gastrointestinal bleed, IDA=Iron defi ciency anemia

a b

c Figure 4: A 20-year-old male with abdominal pain, recurrent malena. Figure 3: Capsule endoscopy in a patient of occult OGIB showing Capsule endoscopy reveals: (a) ulcer in ileum (b) two diverticulae in multiple hemorrhagic spots ileum. (c) Abdominal X-ray showing capsule retention in ileum Journal of Digestive Endoscopy 110 Vol 4 | Issue 4 | October-December 2013 Sodhi, et al.: Capsule endoscopy in obscure gastrointestinal bleed bleeding; one of them had bleeding in jejunum which submucosal hemorrhages with oozing of blood. Resection was resected. The second patient had normal double balloon anastomosis of jejunal segment was done. One patient was enteroscopy and is persistent with intermittent bleeding in lost to follow-up and the fourth one is transfusion dependent. the form of malena. The other four patients refused further Among seven patients of occult OGIB with normal CE, investigations, among them one patient had no further bleed two patients had IDA with positive FOBT and five patients for >6 months and one patient had emergency laparotomy after had IDA with FOBT negative. Among these, three patients 4 weeks of negative CE, due to major upper GI bleed (malena) responded to iron therapy, two patients lost to follow-up, and with hypotension. This patient had intraoperative enteroscopy, two patients were persistent with anemia and were transfusion which revealed a segment of jejunum with multiple areas of dependent [Table 5].

Discussion

The present study evaluated the diagnostic role of CE in patients of OGIB who had initial negative CT-EG. CT-EG revealed positive findings in 9/51 (17.6%) patients, which included GIST in three, duodenal adenocarcinoma in one, duodenal carcinoid in one, jejunal stricture in one, and ileal wall thickening with enhancement and narrowing in two patients [Table 1]. Forty-two (82.3%) patients had negative CT-EG, of which 25 underwent CE for further evaluation. CE revealed additional positive findings in 11/24 (45.8%) of patients. CE revealed mucosal lesions mainly ulcers (seven), vascular malformations (three), and active bleeding without identifiable cause in one patient which were missed in CT-EG, as CT-EG revealed mainly small bowel tumors and strictures. Figure 5: Capsule endoscopy in a patient of overt OGIB showing active bleeding from ileal ulcers Table 5: Follow-up and outcome in patients with normal CT-EG and CE (N=13) Clinical fi nding Other Follow-up investigations Symptomatic (IDA) FOBT −ve, celiac Responded to iron therapy profi le −ve Overt OGIB - No further malena >6 months (malena) Overt OGIB No follow-up (hematochezia) Symptomatic (IDA) FOBT +ve No follow-up Overt OGIB - Recurrent malena (malena) Figure 6: Capsule endoscopy showing multiple ileal ulcers Transfusion dependent Symptomatic (IDA) FOBT −ve, celiac Responded to iron therapy profi le −ve Overt OGIB CTA, leakage of Peroperative enteroscopy (malena) dye in jejunum multiple jejunal submucosal hemorrhages. Resection anastomosis of bleeding segment Symptomatic (IDA) FOBT −ve, celiac Responded to iron therapy profi le −ve Overt OGIB DBE: Bleeding Surgical excision (malena) polyp in jejunum Symptomatic (IDA) FOBT −ve Blood transfusion dependent Overt OGIB DBE: Normal Persistent with intermittent (malena) malena Symptomatic (IDA) FOBT −ve, celiac No follow-up profi le −ive Symptomatic (IDA) FOBT +ve, celiac Blood transfusion dependent profi le −ive FOBT=Fecal occult blood test, IDA=Iron defi ciency anemia, OGIB=Obscure gastrointestinal bleed, DBE=Double balloon enteroscopy, CTA=Computed Figure 7: Capsule endoscopy showing active bleeding in small bowel tomography angiography

Journal of Digestive Endoscopy Vol 4 | Issue 4 | October-December 2013 111 Sodhi, et al.: Capsule endoscopy in obscure gastrointestinal bleed

CE allows direct visualization of the small bowel mucosa and multiple prospective clinical trials and two recent meta-analyses has a high sensitivity for the detection of flat lesions such as in patients with OGIB demonstrates the incremental value ulcers, , or arteriovenous malformations. of CE in diagnosing etiologies of bleeding from the small bowel and the subsequent impact on patient management There is high incidence of negative CT-EG in patients of OGIB and outcomes.[12,33] In a previous study, CE detected bleeding and miss rate of mucosal lesions is high. In a recent study from sources in the small bowel in 57% of the patients who showed our center, 64-slice CT-EG in patients of OGIB picked up normal CT-EG findings. Lesions that were not detected by lesions in 46.9% of patients and the lesions were mainly small CT-EG included mucosal ulcers and angiodysplasias. In that bowel tumors, while as negative CT-EG was seen in 53.1% of study, two patients with small bowel Crohn’s disease were patients which needed further evaluation.[17] Heo et al., recently missed by CT-EG.[24] In our study, CE detected bleeding source evaluated the role of CE in patients with OGIB after negative in 45.8% of patients who had normal CT-EG. The majority of CT-EG. They included 30 patients with OGIB who received lesions were small bowel ulcers and vascular malformations. CE after negative CT-EG. CE revealed a definitive diagnosis in 17 patients (57%), ulcer in nine patients (30%), active bleeding Both CT-EG and CE were negative in 13 (52%) patients; with no identifiable cause in five (17%), in however, CT-EG and CE, both can be complimentary to each two (7%), and Dieulafoy’s lesion in one (3%).[24] Rastogi et al., other. Huprich et al., in 2011 compared CE with multiphase found that diagnostic yield of CE was 42% in his study.[25] CT-EG in OGIB. The sensitivity of CT-EG was significantly greater than that of CE (88 vs 38%, P = 0.008), largely because In the present study, small bowel ulcers were the most common it depicted more small bowel masses. On the basis of these lesions followed by vascular malformations among patients findings, the addition of multiphase CT-EG should be included who had positive CE. Vascular malformations occurred in patients with negative findings CE.[34] in the elderly patients. Previous studies have shown that angiodysplasia were the commonest finding and increasing age Agarwal et al., in 2011 studied the diagnostic yield of CT-EG was the predisposing factor for high diagnostic yield of CE.[26,27] in patients with OGIB and a nondiagnostic CE. CE was Vascular abnormalities account for 80% of OGIB, majority of performed in 52 patients. CT-EG was then performed in 25 of which are angiodysplasias, whereas, small bowel tumors are the 48 patients without a definitive source of bleeding seen on found only in 1.6-2.4% of patients undergoing CE.[28,29] In this CE. The diagnostic yield of CT-EG was 0% (0/11) in patients study, small bowel ulcers were the most common finding and with occult bleeding versus 50% (7/14) in patients with overt occurred in the younger age group, among them two patients bleeding (P < 0.01). The study revealed that in patients with had early Crohn’s disease which were missed by CT-EG. Some a nondiagnostic CE, CT-EG is useful for detecting a source studies have shown that mucosal lesions like aphthoid ulcers, of GI bleeding in patients with overt, but not occult OGIB.[35] are not accurately visualized on CT-EG.[18] Nonsteroidal anti-inflammatory drug enteropathy and inflammatory The role of CT-EG in the evaluation of OGIB is evolving.[14-16] bowel disease have been associated with erosions, ulcers, and Huprich et al., reported a high rate of positive findings by CT-EG strictures of the small bowel presenting as OGIB.[3,4] in a small number of patients with OGIB.[14] In his study, CT-EG detected three small bowel lesions which were undetected by CE. In the present study, diagnostic yield of CE was higher in CT-EG has an additional advantage of evaluating small bowel patients in whom CE was performed within 2 weeks of active strictures, which cause retention of capsule and provide precise GI bleed compared to patients who had CE after 2 weeks and luminal and extraluminal findings that cannot be detected with also the yield was more in overt OGIB compared to occult CE.[14,23] Because of these advantages, some consider CT-EG as OGIB, which is consistent with previous studies. Carey et al., a complementary test to CE, especially in patients with OGIB. found that the diagnostic yield of CE was significantly higher The main limitations of CT-EG include its lower yield than CE when performed in patients with ongoing gastrointestinal in detecting small bowel mucosal lesions, radiation exposure, bleeding than in those with more distant overt OGIB relative poor distention of the small bowel, and limitations with episodes.[30] The diagnostic yield of CE was significantly intravenous iodinated contrast agent administration.[23,33,36] higher in patients with overt OGIB than those with occult OGIB.[24,29,31] In this study, one patient of small bowel Crohn’s There are several pitfalls and limitations in our study as the disease developed capsule retention [Figure 1]. This patient had number of patients were small to generalize the results. CT-EG multiple ileal ulcers with stricture. Previous one large study has and CE was performed once bleeding was settled. There were shown that capsule retention rate in OGIB is 1.4%.[32] five patients in whom the bowel preparation was poor, which hampered the visualization of mucosal details. Among patients with positive CE, eight patients received specific treatment in the form of surgery and coagulation Conclusions therapy of bleeding ulcer on enteroscopy. Four patients received nonspecific treatment in the form of thalidomide, iron In conclusion this study reveals that a normal CT-EG does not therapy, and blood transfusions. Accumulating evidence from guarantee that there is no bleeding source in the small bowel. CE

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